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to 


College  of  ^fjp^iciang  anb  ^urgcong 


d^tttxmtt  llihxavv 


Presented  By 

DR.  WILLIAM  J.  GIES 


to  enrich  the  lihr&ry  resources 
available  to  holders 
il'i'  of  the 

GIES  FELLOWSHIP 

in  Biologic&l  Chemistry 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/atlasofdentalextOOwall 


AN  ATLAS   OF 

DENTAL    EXTRACTIONS 


WITH 


NOTES  ON  THE  CAUSES  AND  RELIEF 
OF  DENTAL  PAIN 


DESIGNED   FOB   THE    USJE    OF   MEDICAL    STUDENTS 
AND    PRACTITIONERS. 


C,    EDWARD    WALLIS,   M.R.C.S.,    L.R.C.P.,    L.D.S. 

DENTAL    SURGEON    AND    LECTURER    ON    DENTAL    SURGERY    KING's    COLLEGE 

HOSPITAL;      ASSISTANT     MEDICAL     OFFICER     (PUBLIC     HEALTH     DEPT.) 

LONDON     COUNTY     COUNCIL  ;      LATE     DENTAL     SURGEON    VICTORIA 

HOSPITAL    FOR    CHILDREN,    CHELSEA,    ETC. 


SECOND    EDITION 


WITH   ELEVEN   PLATES. 


PHILADELPHIA 
BLAKISTON'S    SON    AND    CO. 

1012   WALNUT   STEEET 
1919 


Printed  %n  Great  Britain. 


PREFACE. 

This  "  atlas  "  and  notes  have  been  designed  for  the 
use  of  medical  students  and  practitioners  with  the  object 
of  assisting  them  to  perform  such  emergency  dental 
operations  as  may  be  expected  to  occur  in  a  country 
practice  or  on  board  ship  where  the  services  of  a  dental 
surgeon  cannot  be  obtained. 

A  minimum  number  of  dental  appliances  has  been 
recommended  and  various  means  of  improvising  a  dental 
ch^ir  have  been  shown. 

I  have  to  express  my  great  indebtedness  to  Professor 
Underwood,  Dr.  Harold  Austen,  Mr.  Norman  Bennett, 
and  Mr.  Gr.  K.  Aubrey  for  many  valuable  suggestions, 
and  also  to  Messrs.  Allen  &  Hanburys  for  the  loan  of 
the  blocks. 

C.   EDWARD  WALLIS. 

June,  1909. 


PREFACE   TO  SECOND  EDITION. 

A  SECOND  edition  having  been  called  for  a  complete 
revision  has  taken  place,  which  the  author  hopes  may 
increase  its  usefulness  to  the  medical  practitioner  unable 
to  obtain  the  services  of  a  dental  surgeon. 

C.    EDWARD   WALLIS. 

13,  QxjEEN  Anne  Stbeet, 
London,  W.  1. 


THE     CAUSES    AND    RELIEF    OF    DENTAL 

PAIN. 

In  considering  the  causes  of  toothache  one  must  bear 
in  mind  the  various  structures  of  which  a  tooth  is  com- 
posed, and  the  surrounding  tissues  with  which  it  is  in 
close  relation.  A  tooth  may  be  regarded  as  a  hard, 
unyielding  box,  enclosing  a  highly  sensitive  and  vascular 
pulp  or  "  nerve  "  as  it  is  commonly  called. 

The  portion  of  tooth  which  is  implanted  in  the  jaw  is 
more  or  less  conical  in  shape  and  closely  surrounded  by 
its  bony  socket,  which  is  therefore  a  hollow  cone. 

Between  the  root  and  the  socket  is  a  fibrous  mem- 
brane known  as  the  "  periodontal  membrane,"  in  which  a 
capillary  network  ramifies  for  the  nutrition  of  the  socket 
and  the  external  surface  of  the  root;  and  through  this 
membrane  pass  the  blood-vessels  that  enter  the  pulp. 

Irritation  applied  to  any  vascular  tissue  produces 
hyperemia,  which  may  be  but  transitory,  or  pass  into  the 
condition  of  inflammation  if  the  irritant  be  not  speedily 

removed. 

It  is  important,  therefore,  to  distinguish  hvo  dif event 
sources  of  the  pain  of  toothache  according  as  the  pulp  or 
periodontal  membrane  is  the  part  primarily  affected,  for 
on  the  correctness  of  diagnosis  will  depend  the  chance  of 
successful  treatment. 

Inflammation  of  the  pulp.— The  hypersemia  of  the 
pulp  occurring  in  this  condition  leads  to  swelling  that 
causes  a  darting,   shooting,  or  throbbing   pain    in    the 


2  CAUSES  AND   RELIEF   OF   DENTAL   PAIN. 

tooth,  owing  to  the  resistance  offered  by  the  unyielding 
wall  of  the  pulp  cavity  to  the  expansion  of  the  pulp 
tissue. 

Heat  or  a  lowered  position  of  the  head  intensifies  the 
throbbing,  since  either  will  still  further  increase  the 
congestion. 

As  the  periodontal  membrane  is  not  involved,  pain  is 
not  usually  felt  on  the  tooth  being  pressed  or  bitten  into 
its  socket. 

Infl,ammation  of  the  periodontal  membrane.  —  This 
membrane,  on  becoming  inflamed,  is  thickened,  and 
therefore  raises  the  tooth  in  its  socket ;  hence  it  appears 
lengthened  and  is  bitten  upon  before  its  neighbours  when 
the  jaws  are  closed,  pain  being  produced  from  the  mem- 
brane being  squeezed  between  the  two  unyielding  surfaces 
of  tooth  and  socket. 

The  pain  is  of  a  dull,  heavy,  not  throbbing  character, 
not  worse  at  night,  and  often  relieved  by  heat  and  gene- 
rally in  early  stages  by  pressure. 

The  tooth  is  tender  to  the  slightest  touch,  and  the  gum 
surrounding  it  is  swollen  and  feels  velvety  to  the  finger. 

Irritation  of  the  dental  pnlp. — If  the  irritation  be  long 
continued  and  slight,  an  increased  formation  of  dentine 
may  take  place  from  stimulation  of  the  odontoblasts. 

Irritation  of  the  dental  pulp  may  arise  from : 

(1)  Caries  with  or  without  the  presence  of  cavities. 

(2)  Heat  aLnd  cold,  contact  of  sweet,  sour,  or  acid 
substances. 

(3)  Conduction  of  heat  and  cold  through  a  metal  filling. 

(4)  Exposure  of  dentine  from  any  cause  producing 
loss  of  the  enamel,  such  as  friction  from  bands  or  dental 
plates,  wearing  down  of  teeth  from  excessive  use  or  loss 
of  the  enamel  due  to  overuse  of  a  hard  toothbrush  or 
abrasive  tooth-clj^aning  pastes  or  powders. 


CAUSES  AND   RELIEF   OF   DENTAL   PAIN.  3 

Symptoms. — The  symptoms  depend  upon  the  amount 
of  hypergemia;  thus  slight  discomfort  may  follow  on 
taking  hot  or  cold  fluids,  the  contact  of  cold  air,  etc. 

The  pain,  however,  is  usually  of  a  shooting  or  darting 
character  and  occurring  at  irregular  intervals,  sometimes 
brought  on  by  heat  or  cold,  especially  cold,  or  by  the 
contact  of  sweet,  salt,  or  sour  substances. 

The  tooth  may  also  be  tender  to  the  slightest  touch 
owing  to  an  extension  of  the  hypersemia  to  the  dental 
periosteum. 

Treatment. — When  the  pain  is  due  to  the  presence  of  a 
cavity  in  the  tooth  it  should  be  thoroughly  syringed  with 
warm  water,  and  into  the  cavity  must  be  inserted  a 
small  pellet  of  cotton-wool  that  has  been  dipped  in  one 
of  the  following  local  aneesthetic  substances  (it  is  essen- 
tial to  squeeze  the  excess  from  the  pellet,  as  it  is  undesir- 
able for  the  medicament  to  overflow  into  the  mouth) : 

Oil  of  cloves. 

Eugenol. 

Creosote. 

Oil  of  cinnamon. 

Strong  liquefied  carbolic  acid. 

Warm  saturated  solution  of  carbonate  of  soda. 

Oil  of  peppermint. 

Cocaine  crystals,  especially  the  crystals  dissolved  in 
glycerine  1  in  3. 

Carbolised  resin  is  a  most  convenient  preparation  for 
the  purpose,  as  in  addition  to  relieving  pain  it  serves  as 
a  temporary  stopping  for  two  or  three  days  until  a 
dentist  can  be  seen. 

Formula  for  Carbolised  Resin: 

Eesin •  4  parts 

Carbolic  acid  crystals         .         .         ...  4  parts 

Chloroform         .  .  .  .  .  .  3  parts 


4  CAUSES   AND   RELIEF   OF   DENTAL  PAIN. 

In  cases  in  whicli  owing  to  the  loss  of  the  enamel  the 
dentine  has  become  exposed  and  highly  sensitive  to  heat 
and  cold,  relief  can  be  obtained  almost  immediately  by 
the  application  of  solid  nitrate  of  silver  to  the  sensitive 
area;  the  most  convenient  plan  is  to  fuse  a  little  of  the 
powdered  salt  on  the  end  of  a  probe  or  hair-pin  so  as  to 
form  a  bead,  which  can  be  readily  applied  to  any  part  of 
the  mouth. 

When  there  is  no  visible  cavity  it  is  well  to  treat 
the  pain  on  general  constitutional  principles  with  anti- 
neuralgic  remedies,  such  as  aspirin,  phenacetin,  chloral 
hydrate,  antipyrin,  gelsemium,  and  so  forth.  The 
application  of  iodine  and  aconite  paint  to  the  gums  in  the 
vicinity  of  the  painful  tooth  frequently  affords  great  relief 
by  the  counter-irritation  and  anodyne  effect  produced. 

Iodine  and  Aconite  Paint, 

^     Liquor  iodi  fortis) 

T  •  •,•  r equal  parts. 

Lm.  aconiti  >    ^        ^ 

To  be  applied  to  the  gums  on  a  small  swab  of  cotton- wool  not  more 

than  twice  daily. 

In  severe  and  urgent  cases  it  may  be  necessary  to 
administer  morphine  hypodermically.  In  all  cases, 
however,  in  which  no  cavity  can  be  seen,  the  patient 
should  be  advised  to  consult  a  dentist,  who  may  be  able 
to  find  a  dental  cause  not  discoverable  without  the  use  of 
special  dental  appliances. 

Acute  inflammation  of  the  pulp  is  usually  the  result  of 
its  exposure  or  infection  by  the  advance  of  caries;  it  may, 
however,  be  produced  by  the  fracture  of  a  tooth  due  to  a 
blow,  the  application  of  arsenious  acid  for  destroying  the 
pulp,  or  as  an  extension  of  inflammation  from  the  peri- 
odontal membrane. 

If  a  section  be  made  through  a  tooth  the  pulp  of  which 
is  in  a  state  of  acute  inflammation,  the  pulp  tissue  will  be 


CAUSES   AND  RELIEF   OF  DENTAL   PAIN.  5 

seen  to  be  bright  red,  whereas  a  healthy  dental  pulp  is  of 
a  very  pale  pink  colour. 

Symptoms. — Pain,  usually  of  a  shooting  character, 
brought  on  by  food  pressing  against  the  exposed  surface 
or  by  the  application  of  heat  or  cold,  and  in  its  early 
stages  characteristically  intermittent. 

The  pain  is  ivorse  at  night,  when  the  patient  lies  down 
and  becomes  warm  in  bed,  increased  congestion  being 
thus  produced;  the  pulp  is  squeezed  against  the  hard, 
unyielding  walls  of  the  pulp  cavity. 

The  pain  may  or  may  not  be  referred  by  the  patient 
to  the  tooth  really  affected,  a  lower  tooth  being  fre- 
quently indicated  by  the  patient  as  the  one  in  fault  when 
the  real  source  of  pain  is  an  upper  one. 

Referred  dental  pain,  however,  never  crosses  the 
median  line. 

Examples  of  referred  pain. — Earache  is  frequently  due 
to  a  carious  molar  tooth.  Pain  in  the  bicuspid  or  canine 
region  may  also  be  due  to  a  carious  wisdom  tooth  on  the 
same  side  of  the  mouth. 

Course. — If  the  acute  inflammation  of  the  pulp  be 
allowed  to  run  its  course  untreated,  the  pulp  usually 
becomes  strangulated  at  the  apical  foramen  and  its  death 
results ;  death  of  the  pulp,  however,  may  not  occur  until 
a  second  or  third  attack. 

Treatment.- — -The  first  indication  is  the  relief  of  pain, 
and  this  may  be  accomplished  by  the  same  means  as  for 
the  pain  due  to  irritation  of  the  pulp,  namely,  the  insertion 
of  a  pellet  of  cotton-wool  dipped  in  one  of  the  following : 

Oil  of  cloves,  eugenol,  creosote,  oil  of  cinnamon,  pure 
carbolic  acid,  oil  of  peppermint,  a  warm  saturated  solu- 
tion of  carbonate  of  soda,  or  crystals  of  cocaine ;  carbo- 
lised  resin^  is  also  useful  for  this  purpose,  and  has  the 
1  See  "  Formula  for  Carbolised  Eesin  "  on  p.  3. 


6  CAUSES   AND   RELIEF    OF   DENTAL   PAIN. 

additional  advantage  of  serving  as  a  temporary  stopping 
for  three  or  four  days. 

Treatment. — If  pain  of  a  severe  throbbing  character 
has  lasted  for  some  time  destruction  of  the  dental  pulp 
is  usually  advisable ;  this  is  effected  by  the  application 
of  some  preparation  containing  not  more  than  gr.  yg 
arsenious  acid  to  the  exposed  pulp,  the  preparation 
being  carefully  retained  in  position  by  gutta-percha  or 
wool  soaked  in  sandarac  or  mastic  varnish.  Arsenic 
should  not  as  a  general  rule  be  applied  to  temporary  teeth. 

The  process  of  "killing  the  pulp  "  should  be  in  most 
cases  a  painless  one  ;  in  the  cases  in  which  much  pain 
ensues  the  cause  is  usually  the  application  of  too  tight  a 
dressing,  which  does  not  allow  of  the  expansion  of  the 
pulp  due  to  the  congestion  produced  by  the  arsenic. 
The  application  of  arsenic  for  this  purpose  should  not 
be  undertaken  by  anyone  without  special  training,  as  it 
is  frequently  a  matter  of  considerable  difficulty,  and  may 
cause  sloughing  of  the  gums  and  necrosis  of  the  alveolus 
if  carelessly  performed. 

Gh,ronic  siipiJiirative  inflammation  of  the  pulp  usually 
arises  from  infection  of  the  dental  pulp  that  has  been 
exposed  by  caries. 

Symptoms. — Pain  coming  on  at  irregular  intervals  of  a 
wandering  neuralgic  character,  which  the  patient  may  not 
refer  to  a  tooth  at  all;  the  presence  of  throbbing  is  not  in- 
frequent, and  may  assist  in  locating  the  som^ce  of  the  pain. 

A  paroxysm  is  often  brought  on  by  the  sudden  appli- 
cation of  heat  or  cold,  sweet  or  salt  substances.  The 
characteristic  symptom  of  suppurative  inflammation  of 
the  pulp  is  the  production  of  great  increase  of  pain  on 
the  application  of  heat. 

The  tooth  is  not  tender  unless  the  periodontal  membrane 
is  involved  and  the  gum  is  not  swollen. 


CAUSES  AND   RELIEF   OF  DENTAL  PAIN.  7 

Treatment. — The  application  of  local  anaesthetics  and 
sedatives  on  cotton-wool  as  for  irritation  of  dental  pulp  ; 
opening  the  pulp  chamber  usually  gives  immediate  relief, 
but  is  a  procedure  that  can  only  be  carried  out  with  special 
dental  instruments.  General  constitutional  treatment 
must  therefore  be  used  to  supplement  local  palliative  ap- 
plications until  skilled  dental  treatment  can  be  obtained. 

Polypus  of  the  p?^^^:*.— Sprouting  granulation  of  the 
exposed  surface  of  a  chronically  inflamed  pulp  may  take 
place,  the  granulations  growing  till  the  carious  cavity  is 
completely  filled  by  them,  constituting  what  is  known  as 
polypus  of  the  pulp ;  a  polypus  of  this  kind  is  not  usually 
very  sensitive. 

Treatment. — The  polypus  must  be  cut  away  and  the 
pulp  destroyed  by  arsenious  acid. 

Periodontitis  {dental  'periostitis,  pericementitis). — In- 
flammation of  the  fibrous  and  vascular  membrane  which 
lines  the  socket  of  a  tooth  and  covers  and  nourishes  the 
cementum  is  called  variously  "  dental  periostitis,"  "  peri- 
odontitis," and  "  pericementitis." 

It  may  be  general,  involving  the  periodontal  membrane 
of  all  the  teeth,  or  local,  being  in  that  case  confined  to 
the  socket  of  one  tooth  only;  like  inflammation  elsewhere, 
it  may  be  acute  or  chronic. 

General  inflammation  of  the  periodontal  membrane  is 
dependent  on  some  constitutional  condition,  such  as 
rheumatism,  gout,  tuberculosis,  syphilis,  or  may  be  asso- 
ciated with  one  of  the  exanthem^tous  fevers,  the  inhala- 
tion of  the  fames  of  phosphorus  as  in  match -makers,  the 
administration  of  mercury. 

Localised  periodontitis  may  be  acute,  frequently 
running  on  to  alveolar  abscess,  or  chronic,  in  which 
suppuration  either  does  not  occur  at  all  or  is  restricted 
to  the  periodontal  membrane  near  the  mar  gin  of  the.  socket. 


8  CAUSES   AND  RELIEF    OF  DENTAL   PAIN. 

Acute  localised  periodontitis. — Causes:  (1)  Inflammation 
spreading  from  a  living  inflamed  pulp,  through  the 
apical  foramen  to  the  periodontal  membrane  immediately 
surrounding  it. 

(2)  Direct  absorption  by  the  periodontal  membrane  of 
septic  m'aterial  from  a  putrefying  pulp. 

(3)  Stopping  an  imperfectly  sterilised  tooth  from 
which  septic  material  is  unable  to  escape,  except  through 
the  apical  foramen. 

(4)  Injury  caused  by  a  blow  upon  the  tooth,  injuring  and 
perhaps  leading  to  infection  of  the  periodontal  membrane. 

(5)  The  escape  of  arsenic  from  a  dressing  applied  for 
the  destruction  of  a  dental  pulp. 

(6)  Exposure  and  infection  of  the  periodontal  membrane 
supervening  in  the  condition  known  as  pyorrhoea  alveolaris 
(Riggs'  disease). 

Symptoms. — In  the  early  stages  the  tooth  or  teeth  may 
be  merely  tender  and  uncomfortable ;  later,  however, 
owing  to  the  swelling  of  the  periodontal  membrane,  the 
affected  teeth  become  raised,  as  well  as  loose  and  tender 
to  the  slightest  touch. 

The  gums  also  become  involved,  since  the  periodontal 
membrane  is  reflected  outwards  at  the  margin  of  the 
alveolus,  and  become  swollen  and  deeply  congested, 
presenting  a  velvety  feeling  when  touched  by  the  finger. 

Sudden  changes  of  temperature  or  weather  will  often 
bring  on  or  accentuate  an  attack  of  periodontitis  in  those 
subject  to  this  affection. 

When  periodontitis  is  produced  by  mercury  or  phos- 
phorus, there  is  tenderness  and  loosening  of  the  teeth, 
extreme  congestion  of  the  gums,  which  become  spongy 
and  readily  bleed,  together  with  great  oral  foetor. 

Ulceration  with  sloughing  of  the  gums  and  necrosis  of 
the  jaw  may  ensue. 


CAUSES   AND   RELIEF   OF   DENTAL    PAIN.  9 

Ptyalism  is  especially  marked  in  mercurial  poisoning. 

General  treatment. — Constitutional  :  Remove  the  cause 
if  possible,  as  in  the  case  of  mercury  and  phosphorus 
poisoning. 

Treat  general  condition  if  gouty,  rheumatic,  tuber- 
culous, or  syphilitic. 

Local. — Render  the  mouth  as  aseptic  as  possible  by  the 
use  of  mouth  washes,  of  which  sanitas  combined  with 
chlorate  of  potash  lotion  (gr.  x  to  the  ounce)  is  one  of 
the  best. 

In  cases  in  which  one  or  more  teeth  are  involved, 
counter-irritation  applied  by  first  drying  a  large  area  of 
the  gums  near  the  affected  teeth  and  then  painting  it 
with  iodine  and  aconite  joaint  gives  great  relief. 

Formula'. 

R>     Liquor  iodi  fortis  )  , 

^  ^  .  .  \  equal  parts. 

Liu.  aconiti  j 

This  should  not  be  applied  more  than  twice  or  three 
times  daily,  as  it  tends  to  make  the  mucous  membrane  so 
sore  that  further  applications  become  impossible. 

The  application  of  a  capsicum  plaster,  which  is  a  sort 
of  diminutive  mustard  leaf,  to  the  previously  dried  gum 
also  gives  great  relief ;  it  should  be  held  over  the  root  of 
the  affected  tooth  with  the  finger  until  it  adheres,  and 
then  allowed  to  remain  until  it  falls  off. 

Chronic  localised,  'periodontitis. — This  condition  must  be 
treated  in  the  same  way  as  the  above,  by  general  consti- 
tutional treatment  and  by  the  application  of  the  iodine 
and  aconite  paint  night  and  morning,  or  if  more  con- 
venient by  the  application  of  capsicum  plasters. 

Chronic  suppurative  period.ontitis — p)ijorrh(]ea  alveolaris 
{Biggs'  disease). — The  pathology  of  this  condition  is  very 
obscure ;  it  is  apparently   due  to  a  pyogenic  infection. 


10        CAUSES  AND   RELIEF   OF  DENTAL   PAIN. 

though  in  many  cases  the  pneumococcus  and  Micrococcus 
catarrhalis  may  be  found. 

Symptoms. — Those  of  suppuration  of  the  periodontal 
membrane,  phis  inflammation  of  the  gums  (gingivitis), 
accompanied  by  the  formation  of  deep  pockets,  from 
which  pus  exudes  round  the  necks  of  the  teeth,  leading 
to  destruction  of  the  periodontal  membrane,  absorption  of 
the  alveolus,  and  loosening  of  the  teeth. 

Treatment. — The  treatment  of  this  condition  is  exceed- 
ingly unsatisfactory ;  at  the  same  time  efforts  must  be 
made  to  minimise  the  suppuration  by  the  use  of  antiseptic 
mouth- washes,  such  as  chlorate  of  potash  in  combination 
with  sanitas,  permanganate  of  potash,  etc. 

In  cases  of  suppurative  gingivitis  due  to  dental  neglect, 
which  is  often  mistaken  for  pyorrhoea  alveolaris,  much 
benefit  is  to  be  derived  from  a  vigorous  massaging  of  the 
gums  with  ordinary  sodium  chloride  applied  on  a  pledget 
of  lint  twice  daily  for  a  Aveek  at  least;  arrangements 
should  also  be  made  for  a  thorough  scaling  of  the  teeth 
by  a  dental  surgeon  at  the  earliest  opportunity. 

In  cases  of  genuine  pyorrhoea  alveolaris  zinc  ionisation 
accompanied  with  the  use  of  an  autogenous  vaccine  is 
sometimes  of  great  benefit,  though,  as  before,  a  thorough 
scaling  of  the  teeth  is  an  essential  preliminary. 

Alveolar  abscess. — An  abscess  arising  from  a  tooth  is 
known  as  an  alveolar  abscess  or  "  gum-boil";  it  is  usually 
situated  at  the  end  of  the  root  of  a  tooth. 

Causes. — Extension  of  septic  infection  from  the  pulp 
or  periosteum  of  a  tooth. 

Symptoms. — Those  of   periodontitis   much  intensified, 

e.  g.  the  tooth  is  raised  and  tender;  the  gums  are  swollen, 

deeply  congested;  pus  frequently  wells  up  at  side  of  tooth. 

Sulcus  between  cheek  and  tooth  instead  of  being  hollow 

is  filled  up  by  a  globular  or  diffuse  swelling. 


CAUSES  AND    RELIEF    OF   DENTAL   PAIN.        11 

Sometimes  diffuse  cellulitis  of  the  face  occurs,  the 
whole  cheek  becoming  swollen,  tense,  shining,  very 
painful,  and  the  eye  closed  if  the  abscess  is  connected 
with  an  upper  tooth.  The  pus  from  an  upper  tooth  may 
burrow  into  the  antrum  in  the  case  of  upper  bicuspids  (or 
molars),  or  be  directed  towards  the  palate  (upper  lateral 
incisor)  either  between  the  periosteum  and  the  bone, 
when  there  will  be  great  pain,  or  between  the  periosteum 
and  the  mucous  membrane,  when  there  will  be  but  little 
pain,  since  the  tissue  in  that  situation  is  somewhat  lax 
and  therefore  yields  readily. 

When  an  abscess  it  situated  at  the  root  of  a  lower 
molar,  particularly  a  lower  wisdom  tooth,  trismus  may 
occur  from  : 

-  (1)  Spasm  of  the  masseter,  which  symptom  will  dis- 
appear under  an  ana3Sthetic. 

(2)  Inflammatory  infiltration  of  the  masseter,  in  which 
case  the  administration  of  an  anaesthetic  will  simply 
enable  the  operator  to  apply  the  necessary  force  to  open 
the  jaw  with  a  screw  wedge  or  Mason's  gag. 

An  abscess  from  a  lower  wisdom  tooth  sometimes 
points  beneath  the  angle  of  the  jaw,  and  an  abscess 
connected  with  any  lower  tooth  may  burst  either  through 
the  cheek  or  beneath  the  margin  of  the  mandible. 

The  subinaxillary  lymphatic  glands  may  become 
infected,  in  which  case  they  will  be  swollen  and  tender. 

The  submaxillary  lymphatic  glands  in  children  are 
SGipetimes  infected  with  tubercle,  probably  conveyed  to 
the  glands  by  carious  teeth  with  exposed  pulps. 

.  Treatment  of  alveolar  abscess. — When  an  alveolar 
abscess  has  already  formed,  great  relief  will  usually  be 
obtained  by  incising  the  abscess  in  the  mouth. 

In  cases  in  •  which  the  abscess  is  very  large  and  is 
threatening  to  burst,  outside  the  cheek,  it  is  wise  to  apply 


12        CAUSES  AND  RELIEF    OF  DENTAL   PAIN. 

a  piece  of  gauze  with  flexible  collodion  over  the  thinned 
area  of  skin,  and  thus  to  minimise  the  danger  of  or 
prevent  the  occurrence  of  an  external  opening ;  at  the 
same  time  efforts  must  be  made  to  make  the  abscess 
point  in  the  mouth,  and  this  is  best  done  by  the  applica- 
tion of  a  roasted  dried  fig  or  a  dried  fig  squeezed  dry 
from  boiling  water  and  held  in  the  mouth  over  the 
abscess ;  it  is  often  necessary  to  apply  a  succession  of 
these  fig  poultices. 

Poppy-head  fomentation,  made  by  boiling  two  ounces 
of  bruised  poppy-heads  for  ten  minutes  in  a  pint  of 
water  and  held  in  the  mouth,  often  gives  great  relief  and 
may  shorten  the  course  of  the  affection. 

In  severe  cases  of  alveolar  abscess  extraction  of  the 
tooth  is  the  only  course  open  to  the  medical  practitioner, 
and  the  sooner  it  is  done  the  better  for  the  patient ;  the 
old  idea  that  it  is  necessary  to  wait  till  the  inflammation 
has  subsided  is  often  disastrous,  as  it  may  lead  to  the 
formation  of  an  external  opening  in  the  cheek  and  perma- 
nent scarring  of  the  face. 

An  abscess  arising  from  a  lower  wisdom  tooth  usually 
necessitates  its  extraction  ;  this  is  often  a  matter  of  great 
difficulty,  and  can  only  be  accomplished  by  using  the 
elevator ;  it  sometimes  happens  that  it  is  impossible  to 
reach  the  wisdom  tooth,  in  which  case  it  may  be  necessary 
to  remove  the  second  lower  molar  before  dealing  with  the 
offending  wisdom  tooth. 

Local  ansesthesia  in  the  extraction  of  teeth. — The  hypo- 
dermic injection  of  certain  anaesthetic  solutions  is  in  a 
considerable  proportion  of  cases  successful  in  enabling 
the  extraction  of  teeth  to  be  performed  painlessly.  At  the 
same  time  it  is  essential  for  the  operator  to  know  exactly 
what  he  is  injecting  and  the  exact  amount  and  purity  of 
the  active  ingredient  contained  in  his  injection. 


CAUSES  AND    EELIEF    OF  DENTAL    PAIN.        13 

jSTothing  can  be  more  dangerous  than  the  injection  of 
the  much  advertised  proprietary  local  anaesthetics,  many 
of  which  contain  an  indefinite  amount  of  cocaine,  and 
which  within  the  writer's  knowledge  have  over  and  over 
again  produced  serious  results. 

The  most  widely  used  preparation  for  dental  local 
anaesthesia  is  probably  novocaine  combined  with  adren- 
alin ;  special  dental  tablets  are  made  for  this  purpose,  and 
when  boiled  in  a  test-tube  with  1  c.c.  of  normal  saline 
provide  an  admirable  local  anaesthetic  for  dental  use. 

A  very  satisfactory  syringe  is  that  designed  by  Dr. 
Dawson,  of  Dublin,  as  it  is  readily  sterilisable,  and  more- 

FlG.  1. 


over,  by  reason  of  its  "  finger-rings,"  affords  a  perfect 
command  over  the  barrel  and  piston. 

The  special  "  washerless  "  syringe  sold  by  the  Dental 
Mfg.  Co.  of  London  is  specially  suitable  for  dental 
local  anaesthesia. 

Procedure.  —  (1)  The  patient's  mouth  should  be 
thoroughly  rinsed  with  sanitas  and  water  or  a  perman- 
ganate of  potash  mouth- wash. 

(2)  The  syringe  and  needle  are  next  sterilised  with  1 
in  20  carbolic  lotion. 

(3)  If  novocaine  is  used  the  syringe  should  then  be 
filled  with  17  minims  (1  c.c.)  of  the  solution,  and  then 
an  injection  made  of  about  12  minims  on  the  external 
and  4  minims  on  the  internal  side  of  the  alveolus,  the 

2 


14       CAUSES   AND   RELIEF   OF  DENTAL  PAIN. 

aim  of  the  operator  being  to  surround  the  tooth  with  a 
zone  of  ansesthesia,  and  for  this  purpose  at  least  two 
punctures  are  necessary.  The  point  of  the  syringe  should 
be  inserted  about  3  mm.  from  the  free  edge  of  the  gum 
adjacent  to  the  tooth  to  be  removed  ;  the  needle  should 
be  inserted  quickly  and  the  injection  made  very  slowly, 
the  syringe  being  held  in  position  for  some  seconds  after 
the  requisite  quantity  has  been  injected.  When  the  gum 
becomes  blanched,  and  not  till  then,  the  ansesthesia  may 
be  regarded  as  complete. 

Hypodermic  injections  into  the  gums  should  not  be 
made — 

(1 )  In  inflammatory  or  suppurative  conditions  of  the 
mouth. 

(2)  In  cases  of  alveolar  abscess.  In  such  cases  the 
application  of  cotton- wool  soaked  in  10  per  cent,  novo- 
<3aine  for  some  five  minutes  will  much  alleviate  the  pain 
■of  a  dental  extraction. 

The  local  anaesthesia  that  can  be  produced  by  freezing 
the  gums  with  a  spray  of  ethyl  chloride  is  frequently  very 
useful  in  the  case  of  temporary  teeth  and  readily  acces- 
sible single-rooted  permanent  teeth,  but  it  must  be  borne 
in  mind  that  it  has  a  great  tendency  to  cause  the  teeth  to 
l)ecome  brittle  owing  apparently  to  the  freezing  of  their 
"  organic "  matter,  with  the  result  that  they  may  be 
very  readily  broken  during  the  attempt  at  extraction 
^nd  thus  lead  to  much  difficulty. 


GENERAL  NOTES  ON  EXTRACTION  OF  TEETH.   15 


GENERAL   NOTES   ON   EXTRACTION   OF 
TEETH. 

The  minimiini  number  of  forceps  that  can  be  expected 
to  deal  with  any  ordinary  case  of  extraction  is  five,  and 
tliis  number  combined  with  a  "  fish-tail "  elevator  will  be 
sufiicient  for  practically  every  tooth.  In  Figs.  2  and  3 
the  patterns  suggested  are  shown  together  with  a  pair 
of  "conveying  forceps"  such  as  are  very  useful  for  apply- 
ing medicaments  on  cotton-wool  for  the  relief  of  pain, 
and  also  a  dental  probe  for  ascertaining  the  exact  position 
and  extent  of  carious  cavities. 

The  use  of  so-called  "straight"  forceps  for  lower  molar 
and  bicuspid  teeth  is  not  recommended,  as  they  are 
exceedingly  difficult  to  use  and  do  not  provide  nearly  as 
much  leverage  as  those  of  the  so-called  "hawksbill" 
pattern  as  shown  here.  The  blades  of  all  dental  forceps 
must  be  bevelled  so  that  they  grasp  the  teeth  on  a  flat  and 
not  a  sharp  edge,  as  is  frequently  the  case  with  ill- 
clesigned  forceps,  which  simply  break  the  teeth  instead  of 
grasping  them. 

The  "  straight "  elevator  is  not  recommended,  as  not 
only  is  it  difficult  to*  use  but  is  an  exceedingly  dangerous 
instrument  in  the  hands  of  one  nnaccustomed  to  its  use. 

It  is  of  the  utmost  importance  that  all  instruments 
used  for  extracting  teeth  should  be  efficiently  sterilised, 
■either  by  boiling  or  else  by  prolonged  soaking  in  a  solu- 
tion of  carbolic  acid  (1  in  20)  or  lysol;  it  is  also  essential 
that  the  forceps  should  be  clean  in  the  ordinary  sense  of 
the  word  before  being  placed  in  the  antiseptic  lotion. 

Inasmuch  as  few  medical  practitioners  possess  the 
luxury  of  a  dental  operating  chair,  a  convenient  substitute 


16  GENERAL  NOTES  ON  EXTRACTION  OF  TEETH. 


6 
I— I 


GENERAL  NOTES  ON  EXTRACTION  OF  TEETH.   17 


■CO 

6 


18  GENERAL  NOTES  ON  EXTRACTION  OF  TEE'J^H. 

can  be  readily  devised  as  shown  in  Fig.  4  by  placing  two 
strong  cLairs  back  to  back  against  a  wall  in  such  a  way 
as  to  prevent  the  chair  in  front  being  tilted  backwards  by 
the  flinching  of  the  patient  or  the  efforts  of  the  operator. 
This    plan,    combined  with  such  other  positions   as  ar& 

Fig.  4. 


A.  Cnsliion  on  back  of  chairs.     B.  Chair  resting  firmly  against  a  wall. 

shown  in  dealing  with  particular  teeth,  is  sufficient  for 
every  case. 

Special  care  must  be  taken  when  extracting  a  tooth 
that  stands  alone ;  it  frequently  happens  that  the  gum 
is  firmly  adherent  to  a  tooth  of  this  kind  and  may  there- 
fore be  seriously  torn  during  the  process  of  extraction ; 
in  such  a  case  it  may  be  necessary  to  cut  away  the  tag^ 
of  gum  with  a  lancet  or  scissors. 


THE   EXTRACTION   OF  TEMPORARY  TEETH.     19 


THE    EXTRACTION    OF    TEMPORARY 
TEETH. 

All  the  temporary  teeth  except  the  molars  have  one 
root. 

There  are  no  bicuspids  in  the  temporary  dentition. 

The  position  of  the  temporary  molars  is  occupied  by 
the  bicuspids  in  the  permanent  dentition. 

The  hiciispids  erupt  between  the  roots  of  the  "tem- 
porary molars,"  and  therefore  occupy  their  position 
when  they  are  lost. 

In  extracting  the  temf  ovarii  teeth  the  paiient  should  he 

Fig.  5. 


The  temporary  teeth. 

placed  in  the  sayne  position  as  for  the  corresponding  per- 
manent teeth. 

General  principles. — Grasp  the  crown  of  the  tooth 
firmly  in  the  forceps. 

In  the  case  of  a  temporary  molar  it  is  important  tO' 
avoid  pressing  the  forceps  upwards  or  downwards  to  any 
appreciable  extent  for  fear  of  removing  the  crown  of  an 
on-coming  bicuspid  which  Ties  between  its  roots  ready 
to  take  its  place. 

For  tipper  incisors  or  canines  use  "  straight  "  or  bayonet 
root  forceps. 

For  upper  molars  use  right  or  left  upper  molar  forceps 
or  bayonet  root  forceps  in  cases  where  the  crown  is 
much  broken  down. 


20  THE  EXTRACTION  OF  TEMPORARY  TEETH. 

For  lo'wer  incisors  and  canines  use  lower  hawksbill 
root  forceps  ;  the  same  forceps  can  be  used  on  either  side 
of  the  mouth. 

For  lower  temjyorari/  molars  use  lower  hawksbill 
molar  forceps  or  lower  hawksbill  root  forceps. 

Broken-down  temporary  teeth  and  roots  can  either  be 
extracted  with  root  forceps  or  prised  out  with  the  "  fish 
tail "  elevator,  making  use  of  an  adjacent  tooth  as  a 
fulcrum. 

It  is  quite  'unnecessary  to  have  special  forceps  for 
temporary  teeth. 

It  is  important  to  avoid  extracting  prematurely  a 
second  temporaru  molar ;  loss  of  this  tooth  ma}^  lead  to  a 
moving  forward  of  the  adjacent  first  permanent  molar 
and  consequent  crowding  and  irregularity  of  the  bicuspid 
teeth. 

The  temporary  canines  should  also  be  retained  until 
their  permanent  successors  show  signs  of  erupting ; 
premature  extraction  of  the  temporary  canines  allows 
the  bicuspid  teeth  to  move  forward  and  thus  may  lead 
to  the  deformity  of  projecting  canine  teeth. 

Undue  retention  of  the  temporary  teeth  may,  on  the 
other  hand,  lead  to  irregularity  of  the  permanent 
■successors  ;  in  cases  of  doubt  it  may  be  well  to  postpone 
extraction  until  the  advice  of  a  dental  surgeon  can  be 
obtained. 

Dentition  Table. 

The  following  table  shows  the  order  in  which  the  milk 
teeth  and  permanent  teeth  appear,  and  the  average  age 
at  their  eruption.  There  are  wide  variations  as  to  time, 
and  great  irregularity  in  the  order  of  their  appearance. 

Milk  teeth. — The  first  dentition  bea^ins  at  the  sixth  or 


HAEMORRHAGE   AFTER   EXTRACTION. 


21 


seventh  month,  and  is  completed  by  about  the   second 
year. 

(1)  lower,  6th  month;   (2)  upper, 

7th  month. 
(1)   upper,  9th  month;   (2)  lower, 

10th  month. 
12th  month. 
18th  month. 
2nd  year  (often  later). 
The   full  primary  dentition  is  20  teeth ;    10  in  each 
jaw. 


Central  incisors 

Lateral  incisors 

First  molars 
Canines 
Second  molars 


Permanent  teeth  : 
First  molars    . 
Lower  central  incisors 
Upper  central  incisors 
Lateral  incisors 
First  bicuspid 
Second  bicuspid 
Canines  . 
Second  molars 
Third  molars  (wisdom) 


6^  years 

7       „ 


9 

10 
11 
12 


13       „ 

17  to  25  years, 

or  at  any  later  period. 
The  full  permanent  dentition  is  32  teeth;  1 6  in  each  jaw. 


HEMORRHAGE    AFTER    EXTRACTION: 
TREATMENT. 

Local. — In  slight  cases  it  is  sufficient  for  the  patient  to 
sit  quiet  with  cold  or  iced  water  in  his  mouth ;  where  ice 
cannot  be  obtained  holding  vevj/  hot  water  in  the  same  way 
is  often  successful,  especially  if  alum  be  dissolved  therein. 

It  is  not  infrequent,  however,  that  blood  will  continue 
to  well   up    from  the  socket  from  which  the  tooth  has 


22  HEMORRHAGE  AFTER   EXTRACTION. 

been  removed  ;  in  such  a  case  it  is  necessary  to  syringe 
the  socket  with  ice-cold  or  very  hot  water  or  boric  lotion, 
and  then  to  apply  pressure  to  the  bleeding  point  by  firmly 
plugging  the  socket  with  cotton-wool  or  lint  soaked  in 
fresh  adrenalin  or  other  supra-renal  gland  preparation  ; 
the  application  of  tannin,  either  as  glycerin  of  tannin  or 
on  wool  soaked  in  hazeline  and  powdered  with  tannin, 
answers  in  many  cases.  Perchloride  of  iron  is  a  most 
unsatisfactory  remedy,  and  should  only  be  used  as  a  last 
resource  when  nothing  else  is  obtainable. 

Gonstitutiunal. — It  is  not  uncommon  for  an  operator  to 
be  warned  by  the  patient  that  excessive  bleeding  has  pre- 
viously followed  the  infliction  of  a  cut  or  the  extraction 
of  a  tooth.  It  has  been  shown  that  a  large  proportion  of 
these  cases  are  due  to  insufficient  coagulability  of  the  blood 
owing  to  an  insufficiency  of  calcium  salts  ;  it  is  therefore 
wise  in  such  cases  to  administer  one  of  the  drugs  which  are 
known  to  rapidly  increase  the  coagulability  of  the  blood. 

Calcium  lactate,  calcium  chloride,  and  magnesium 
carbonate  have  all  been  shown  to  produce  this  effect  in 
a  marked  degree  within  the  space  of  an  hour  or  so  ;  the 
salt  selected  should  be  administered  in  a  single  dose  of 
3J  the  night  before  the  proposed  operation. 

The  best  and  most  pleasant  to  take  is  calcium  lactate, 
which  may  be  administered  in  compressed  tablets  or  in  a 
draught  such  as  the  following  : 

P)   Calcii  lactatis     .         .         .         .         .         .         .         5j- 

Syrup q.s. 

Aq.  ad 3J. 

Fiat  haustus. — To  be  taken  as  a  draught  the  night  before  the 
dental  extraction  takes  place. 

The  effect  of  these  salts  appears  to  last  about  three 
to  four  days,  so  that  in  the  event  of  dental  extractions 
being  performed  on  successive  days  a  second  dose  is  not 
called  for. 


PMN   AFTER   EXTRACTION.  23 

PAIN   AFTER   EXTRACTION. 

Pain  after  the  extraction  of  a  tooth  may  be  due  to  the 
lateral  displacement  of  the  alveolus  which  is  brought 
about  by  the  application  of  the  forceps  ;  this  can  be 
minimised  by  applying  firmly  a  finger  and  thumb  after 
the  tooth  has  been  removed  and  so  restoring  the  alveolus 
to  its  former  position. 

Besides  this,  owing  to  the  socket  becoming  septic 
either  from  the  operator  making  use  of  unsterilised 
instruments  or  else  operating  in  a  mouth  that  is  very 
foul,  pain  may  continue  in  a  tooth  socket  for  a  consider- 
able time. 

To  avoid  this  every  mouth,  before  operation,  should  be 
made  as  clean  as  possible  by  the  use  of  tooth  powder  and 
sanitas  and  permanganate  of  potassium  mouth-washes,^ 
and  after  the  extraction  has  taken  place  every  effort  must 
be  made  to  keep  the  socket  free  from  the  remains  of  food 
and  other  decomposable  matter.  If,  two  or  three  days 
after  the  extraction,  the  patient  complains  of  pain  in  the 
socket,  the  treatment  is  to  keep  it  syringed  out  with 
sanitas  and  water  or  weak  permanganate  lotion. 

A  pledget  of  cotton-wool  soaked  in  liquor  potassae  and 
pure  carbolic  acid,  equal  parts,  usually  affords  immediate 
relief  from  pain  after  the  socket  has  been  syringed  out 
in  this  way. 


INDEX. 


Aconite  and  iodine  paint,  4 
Acute  inflammation  of  pulp,  4 
Alveolar  abscess,  10 
AnEesthesia,  local,  12 
Anodyne  applications,  3 
Arsenic  for  dental  pulp,  6 

Bicuspids,  extraction  of  riglit  and  left 
upper,  plate  3 

of  i-ight  lower,  plate  4 

of  left  lower,  plate  5 

Biniodide  of  mercury,  15 

Calcium  chloride,  22 

—  lactate,  22 

Canines,  extraction  of  upper,  plate  1 
of  lower,  plate  2 

—  temporary,  premature   extraction 
of,  20 

Carbolic  acid,  3,  5 
Carbolised  resin,  3 
Carbonate  of  magnesium,  22 
Chair,  operating,  18 
Chloride  of  ethyl,  14 
Chronic  periodontitis,  7 

—  suppiirative  inflammation  of  pulp,  6 
Collodion,  flexible,  12 


Dentition  table,  20 
Destruction      of      dental 
arsenic,  6 


pulp     by 


Earache,  5 

Elevator,  use  of,  plates  10,  11,  and 

page  15 
Ei-uption  of  teeth,  order  of,  21 
Ethyl  chloride,  14 
Extraction,  haemorrhage  after,  21 

—  pain  after,  23 

—  of  temporary  teeth,  19,  20 

—  of    permanent    teeth    (see    under 
names  of  teeth). 

Fig-poultice,  12 
"  Fish-tail  "  elevator,  plate  10 
Fomentations,  poppy-head,  12 
Forceps,  16,  17 

Gag,  Mason's,  11 
Gingivitis,  10 

—  naistaken  for  pyorrhoea  alveolaris,. 
10 

Glands,  infection  of,  11 
Gum-boil,  10 

Haemophilia,  21 

Haemorrhage  after  extraction,  21 

Hawksbill  forceps,  15 

Improvised  oj)erating  chair,  18 
Incisors,  extraction  of  upper,  pla.te  1 

—  —  of  lower,  plate  2 
Inflammation  of  the  pulp,  1,  4 


"26 


INDEX. 


Inflammation    of    periodontal   mem- 
brane, 2 
Instrviments,  sterilisation  of,  15 
Iodine  and  aconite  paint,  4 

Lactate  of  calcium  in  lisemopliilia,  22 
Local  ansestliesia,  12 

Mason's  gag,  11 

Masseter,  spasm  of,  11 

Mercurial  poisoning,  7 

Mercury,  biniodide  of,  15 

Molars,    extraction    of    right   upper, 

plate  6 
of  left  aipper,  plate  7 

—  —  of  riglit  lower,  plate  8 

—  —  of  left  lower,  plate  9 

—  pi-emature   extraction   of    tempo- 
rary, 20 

Novocaine,  13 

Operating  cliair,  18 

Pain  after  extraction,  23 

—  referred,  5 
Percbloride  of  iron,  22 
Periodontitis,  7 
Phosphorus  poisoning,  7 
Polypus  of  pulp,  7 
Poppy-head  fomentations,  12 


Potassium  chlorate,  9 
Ptyalism,  9 

Pulp,  inflammation  of,  4 
Pyorrhoea  alveolaris,  8 

Referred  pain,  5 

Resin,  carbolised,  3 

Riggs'  disease,  8 

Roots,  extraction  of,  plates  10,  11 

Scarring  of  face,  12 
"Straight"  forceps,  15  and  platfe  1 
Stumps,  extraction  of,  plates  10, 11 
Suppurative  inflammation  of  dental 

pulp,  6 
Syringe,  Dawson's,  13 

Tannin  in  haemorrhage,  22 

Teeth,  order  of  eruption  of,  21 

■ —  permanent,  plates  1-11 

—  temporary,  19 

Temporary  teeth,  extraction  of,  19 

■ —  —  premature  extraction  of,  20 

shapes,  19 

Trismus,  11 

Yaccines  in  pyorrhcea,  10 

Wisdom  teeth,  extraction   of   lower, 

plate  10 
of  upper,  plates  6,  7 

Zinc  ionisation  in  pyorrhoea,  10 


LIST  OF  PLATES. 


1.  Extraction  of  Upper  Incisors  and  Canines. 

2.  Extraction  of  Lower  Incisors,  Lower  Canines,  and  Incisor 

AND  Canine  Roots. 

3.  Extraction  of  Right  and  Left  Upper  Bicuspids. 

4.  Extraction  of  Right  Lower   Bicuspids   and    Lower   Roots 

ON  THE  Right  Side  op  the  Mouth. 

5.  Extraction  op  Left   Lower    Incisors,    Bicuspids,    and   all 

Roots  on  Left  Side  op  Mouth. 

6.  Extraction  of  Right  Upper  Molars. 

7.  Extraction  of  Left  Upper  Molars. 

8.  Extraction  op  Right  Lower  Molars. 

9.  Extraction  of  Left  Lower  Molars. 

10.  Extraction  of  Upper  and  Lower  Roots  and  Lower  Wisdom 

Teeth. 

11.  The  Use  of  the  Elevator  for   Extracting  Lower   Stumps 

AND  Lower  Wisdom  Teeth. 


PLATE    1. 

Extraction  of  Upper  Incisors  and  Canines. 


fe 

< 

Q 

Q 

^ 

<1 

CO 

03 

• 

c 

1 — 1 

m 

o 

H 

!z; 

H 

1— 1 

<1 

M 

^ 

^ 
fM 

CM 

CM 

U^ 


o 

b 


- 

Ph 

03 

in 

■A 

o 

<A 

>% 

ce 

cq 

"^ 

-(-:> 

_g 

a 

'r-] 

.2 

a> 

-p 

ri2 

ft 

bJD 

bD 

rH 

m 

4^ 

'^ 

rjl 

Pi 

'id 

cS 

d  ^ 

s  s 

be  ^ 

fcl)g 

cC    c3 

ce  2 

—  -^^ 

rH     -fJ 

■^    c3 

fl  -S 

.1=;  «ti 

§  2 

^  ^ 

.^  -(-) 

ti:  3i 

ri~-     2 

=3    2 

.2^ 

ni 

a3   9 

"3  ^ 

S.1 

O    fli 

.      O      r^ 

o  2 

tooth 
anter 
t  teetl 

:of  t 
at  tl 
ent. 

's^  s 

di  ^  d 

si    H  ^r; 

-+-i    rS        - 

photos. 

ards  between  i 
er  to  loosen,  ai 
b  from  its  attac 

-U     tl-l 

hen  withdraw 
alveolus  toge 
11  the  case  of 

S  ^'p-^ 

-^^     CO  -r-i 

.3     ^     !-, 

02    -t^     d 

9    M    c3 

a 

o 
U. 

o 

Apply  blades  ; 

Press  forcibly 

Rock  gently  ii 

order  to  f 

When  quite  lo 
r  extraction  pres; 
specially  import 

s 

,2 

-2.2 

'+3 
C3 

^S 

y 

a 

a 

< 

PLATE    2. 

Extraction  of  Lower  Canjnes,  all  Lower  Incisors, 
AND  Incisor  and  Canine  Roots. 


w. 

EH 

O 

O 

P^ 

H 

!?; 

S 

<ji 

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p 

^ 

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0^ 

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m. 

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a> 

o 

m 

^ 

-p 

1— 1 

0) 

■4J 

Q 

0 
0 

;?; 

u 

ol 

i 

•N 

Tj: 

CQ 

•S 

P5 

'O! 

o 

<B 

m 

H 

C« 

O 

CO 

h- 1 

JH 

ce 

0 

E3 

pi 

O 

(S 

yA 

zn 

02 

kJ 

'0 

J 

S 

< 

•  rH 

r^ 

0 

m 

^ 

H 

^ 

^ 

,_, 

s 

1 

<; 

1 

O 

pq 

2f 

!^' 

P^ 

^ 

o 

yA 

Ph 

o 

ih; 

o 

1— 1 

H 

O 

<; 

2; 

^ 

><i 

S 

li:  "J  —         0^ 


(N3dO) 
3ZIS  Tin  J 


w 


'CD  ^ 


s 

ce 

oa 

^ 

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rH 

r— ; 

-+^ 

c 

c 

'^ 

J 

cS 

i 

^3 

(M 

"^ 

'o 

O 
-(J 

5 

pH 

ffl 

f^ 

o   bt 

'+2 

fc-. 

02     fl 

I 

.3 

=4-1 
O 

09 

•1=  ce 
o  ^^ 

c3 

<D 

-+i 

ffii 

O 

"^  S 

r^ 

-1^ 

•+i 

c  ^ 

!=1 

S 

-f^    a; 

+3 

;=,   c 

1 

-(J 

fcc 

Si 

5-1     ? 

t^  o 

.—•     0^ 

£ 

^^  le 

2 

eg 
o 

c    a: 

cc 

^ 

O    a: 

t« 

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_ 

a 

p 

^ 

•  r-l 

(J 

o 

o 

'   CZ3 

— ^    QJ      -      ?^ 


^P^^ 


S8 

"E 

Cu 

< 


PL, 

o 


PLATE  3. 

EXTEAOTION    OF    RiGHT    AND   LeFT    UpPFII    BiCUSPIDS. 


o 

I— I 

pq 


H 

CO 

Ii< 

1^ 

H 

H^ 

CH 

O 

< 

^ 

Pm 

M 

O 

1— 1 

P^ 

Er 

o 

^ 

o 

t— 1 

^ 

o 

•< 

h 

H 

cS 

/  ^ 

M  4S 

3  c> 

if^'rt  ^• 

££=^     2 

s  rt  g 

§3^ 

r'   ^   c3 

-   <i^   3 

!»      52    i^ 

-^    I^  ' — ' 

'^        r-i     ^^ 

:3  S  t« 

=5  "S'S 

2^05       2 

r^    tH    ,4^              r-H 

d    _                (D 

"      -H    rS      O      M 

photos. 
1  the  lie 
he  tootl 
-er  alveo 
Y  the  to 

alveolu 

^  g^^  ^J 

^     1     S     ^rS^ 

^    ^     CC     CD     ii  q-l 

.;3    CD    O  ^  T3    o 

rf      02      O      O      f^   =i 

,refully 
upward 

order  h 
owhig  t 
se  then 

the  wa 

as                r-<                 O      (/} 

"^•-  a.2  S 

CA 

a;  ^   >-.  o   ^  ^ 

D. 

V 
^ 

o 

>^  w    .  .  n:3    S  -e 

o 

Appl 
Pres 

Eock 

Whe 
r  extrac 

c 

o 

a> 

-ij 

'■^Z 

^j 

CS 

<^ 

o 

a 

a 

< 

-      PLATE  4. 

EXTEAGTION   OF    RiGHT    LoWER,    BlOUSPIDS    AND     LoWER 

Roots  on  the  Right  Side  of  the  Mouth. 


53 
Q 

m 


m 


(N3dO) 
3ZIS  Tin  J 


^ 

o 

M 

b 

o 

P^ 

^ 

^ 

e: 

K 

H 

<1 

-1 

1 — 1 

H^ 

Cj 

Pi 

^ 

-< 

p   o 

O    !3 
0/ 

2^3 


Ph    *■ 


I— I  s 


o 


C; 


c 


p^ 


'!^ 

«s 

^ 

^ 

o 

_1 

o 

b 

< 

^ 

>< 

H 

•S  ,£3  h3  .3  +3 
S  S  I  §  ^ 

3      O      ^      gr^ 


<S 


O) 


O!  OJ  „ 
IK  r5  rS 
n^  -P     ^ 


o  1:      cs  -^ 

b£"^  F  o  r^  n^ 

Oj    O    CD    O    g    o 


fe 


r^     ^     CD 
CO     P4   fl 


"S  fl 

0) 

0| 

^.2 

O 

2^ 

=(-i 

o 

FfM 

Li 

« 

OJ 

OJ 

§^ 

fl 

^ 

Pi 

o  rt 


be 


2  ^ 

^  s  s 
la  i| 

^  ' — '   "^     "X* 

o  1i  '"^   be 

•  ^     O 
O     ^   =G     3 

^  72  ^  'o 

0  O   -t-^    O) 

Oi    o    o    t> 

01  -*^    r^    rQ 

'^  ^  4^  -2 
£  3       2 

K      o      cc    -*-^ 

O    r.    r- 
bi    X    ai 
..    M    O    O    t/j 

W    ^       '7^    £ 
«    fi    p;    IZ!    _ 

o  o  o  e,  s 


C 

a 
a 
< 


o 


PLATE  5. 

ExTEAOTioN  OF  Left  Lower  Inoisoes,  Bicusfids,  and 
ALL  Roots  on  Left  Side  op  Mouth. 


H  ■ 


Q 


c 


o 
o 


(N3d0) 
3ZIS  Tin  J 


u 

OS 

o 

13 

1— 1 

OJ 

m 

o 

^4 

rn 

^ 

I—* 

'&D 

o 

.S 

f» 

'S 

o 

bD 

:< 

_fl 

1— 1 

'S 

o 

P5 

CO 

rH 

1—1 

o 

^ 

CO 

o 

o 

PI 

vA 

?H 

« 

H 

^ 

pu 

o 

H 

^ 

rA 

1 

m 

fcn 

O 

)^ 

J2; 

o 

h- 1 

H 

o 

<:: 

D^ 

&H 

M 

f^ 

a)   O 


CO  4^ 


F 


r^^ 


Pi    0) 


0 

PI 

o 

^ 

Ph 

ctf 

O 

fl 

O 

cti 

cS 

q-i 

O 

■r-t 

hr 

'^    5c 


Pm 


^75 


S    eg 

3  ^ 

fcj:t^ 

s 

be  o 

.3  Ti 

^  a 

rt    c^ 

S     M 

P  rc! 

H    ?^ 

b   c« 

S  ^ 

^^       !=^ 

<V    -rl         . 

'^    r^    "^ 

_j     -+J    r^ 

TS      r-      O 

!=^  ^  '^ 

f^ 

OS    .3^    !» 

<v 

r^^    ^ 

^2 

-t^      ,1    •  rt 

QJ 

3  o   S 
Q  o 

O 
■4J 

S  0^ 


.3    cS 


tn 
a 
a> 
u 

o 
U. 


c 
_o 

03 

a 
< 


$  M  ci  o 


.       ^, 
?>      fe      "^      O) 

^    ^.^    §? 

f^r— I  CP 

O  -rrt   +^     o. 

O      '-'      "      rH 

^^  ^_s 

_^-   02     S   '-+2 

Oi  5P  2  S 


^ 


PLATE  6. 

Extraction  of  Right  Uppepi,  Molaph. 


-iJ 

rf, 

O 

P^ 

P^ 

cS 

tj    +-'    -P   rrt   J- 

-w  ^^  .2    H  .Si 


:j5 


•ep-Biq  a8:;no 


a. 

o 

P 

H 

^ 

H 

o 

<^ 

P^ 

1— 1 

Pm 

o 

12; 

o 

H 

o 

<; 

ci 

;l-i 

XI 

H 

■epiJi^q  .13^X10 


13    03    2    ° 

o   .^^ 

•"  H    m    o5 

M   OJD+e    d 

f^      2  <^ 

03   o   o   a 

p  te  '^^ 

ar  for 
has  t 
viccal 
3  two 

_i3 

■O      OJ   '^   r^ 

-jd 

"^   ^   S 

S'ii- 

L. 

03  '"           03 

1 

pL,^-^  03    ^ 

§^1^1 

ia  pi  s  » 

rrL^    >  -tJ 

ScOocpl 

w 

.S  S 


ra  fe  fl  03  a 

i-r<    rt    S    CO    S 


•73  03  o  -p  -e 

^    J.4--.    03 


S-5 


03    ?3  ncj  o3 

o;  ^  03  ^  ^ 

r^    g  S  ><    03 

-p     S  q-i  03  -rH 


O  O  <5     ^  4^ 

4!j  rH  3     O  '* 

O  O  ^  'P,     ^ 

f^  g  »  & 


,  OJ 


""  -s  ^  s  «  "" 

eg    rCl    ^      CO    .pH    ^ 


^ 


O 


P-,  bo 

8. a 


o 
o 

•  S 

o3 
'ci 
Pa 

be 


■73 
OJ    I) 


Ti    o 


p  «;  f  t 
&-S  o 


42   si_s   o  '::t5 

•r-l      r-(    'T'.     _, 


a 

u 
o 


a 
a 
< 


3  S  !3 


CO 


CB  ^ 


-^^    o    S    §    g    O 

^_0   ^    ^   r^  - 


p-l 


o  .If 


<^ 


PLATE  7. 

Extraction  of  Left  Upper  Molars. 


\^ 


o 

p-( 


o 
o 


<1 

EH 


•ap-exq  Ja^iiQ 


*  -rt  'o 


<»  <B  S 

CO  '§    03  "b    S  -S 

_g      !ZJ  fH    r^      QJ      O      S 

^  ^  O      ^  nj  fH    ®  , 

5.cefl'7JOrrt5o 


ft  2  'H  s  oj 
ft  S  53  5-  01 
5^-^  ft  § 

■^         ft  ^nd 

'tf  o  ;s  ^  s 

^  -p 

S    05    CD 

aj  ^  CO 

o 
o 
*-* 

03 
O 

9   -4^   ?    rJi 

03    CO   ra 

1? 

CO   ;i 

,i^ 

The  first  and 
three    root 
palatine) ; 
tooth)   has 
like    the   fi 

quently  th 
shape   or 
reason  it  i 

03 
ft 
ft 

c3 


1=1 

c3 


S    0)  --^   CC  -^  "ilj 


b    0) 


■       ^    fl    O    OJ 

bf]    ^      ^-,      CS    .rH 


-y     rH 


^    *  n:J  r-T 


^1    =S    cfi 

c2  4^     ^  I 


n  <^  S 

o  cS  P 

■1     r'     hr  ™ 


to  3  ■ 


=g  fl 


9S  rJ:5    O    c«    to  -(J  P=l 


to 

a 

0) 

tj 

o 


^1 


■^ 


i=!    ^' 


O! 


S       n^   o 


cS 


"^  ;^   o 


^    - 


M  rt 


03 


-(J      © 

Ph 


O    o 


rf 


C 
'■3 

fa 
o 


< 


M  LJ  ?^ 


PLATE  8. 

ExTEA(yrioN  of  Right  Lower  Molaes. 


(035013) 

3ZIS  mnn 


02  0)  aj 

Q)    r;    tn 


o 


00 

o 

K 
H 

1— 1 
P^ 

Ph 

15^ 

C 

^ 

o 

H-l 

&■ 

o 

<^ 

05 

H 

M 

H 

i.li4||    o  5  g 


O    rd 

rG   be 


ft 
o 


"^ 

x  ^ 

c 

<X) 

0)  ^' 

0 

^ 

o  +2 

-+— * 

=3 

+i     Pi 

_^ 

^§ 

S 

g  r 

0 

_o3 

i 

02 

8  ^ 

"V 

rj      C3 

j^ 

■  ce 

^^ 

ci 

P  ^ 

+3    .'^ 

bJD 

3  12 

ri    r^ 

.^ 

02 

■^     S 

''^  i^ 

0 

i=i     »^ 

02  ,-^* 

p 

P   "^ 

•r-i    OJ 

P     rf 

■+J   +^ 

•rH       cS 

^ 

o 

3       S 

^      . 

S    -^^ 

o 

^ 

s  -^^ 

G 

Ctf    r^ 

cc 

o 

r^        O 

•  i-H  r^ 

J_J         1 1 

^ 

~^  o 

-g      O! 

"^ 

cr 

+3  ^ 

X3  0 

o  ^ 

2 

o 

■5  2 

>i   i-H 

o  .gq-i   s   S^   o 
"o  Ji  "" 


S-::  2  2  J;  gn 


^   ar-43   >^ 


t^'l  ^  ;^    =^    ^    a.    O 


^   ts   a;  -^ 
o3    0    ^  "*^ 

OJ  «<-i 

'3 

be 

.. 

<i2   0   c^  0 

00   „ 

0 

a 

^ 

0 

^1^        a     le 

2  =* 

rt^ 

U. 

U^  2  § 

'a! 

■3 

0 

c 
^0 

2I 

be 

cS 

=4H 

^i 
^ 

^ 

"a 

-4-> 

i 

a 

to 

< 

C5    r-H 
02  'c3 


f>  - 


5    <X) 


^  ."« 


d    (]j 


I — I 


PLATE  9. 

EXTEAOTION    OF    LeFT    LoWEE    MoLARS. 


o 


1^ 
o 

o 

l-H 

o 

9^ 
>< 


pq 


u 

o 


3    ^ 

op  OS 

O    ^ 
5-*  ri 


>~,+^ 


^^Ti 


o 

eg    g 

o    S 

^^ 

c^    O 
m 

0)      r-l 


S    CD 
.1^    ^ 


pi  ,^3 


^5 


be  o 


-^  o  ^ 
<=  a;  =^=^ 

CD    O  ^ 


fH    -t^ 


5£  <x>  oi 
pi — I   m 

"o    >.^ 

-&  S  P 
o3  2  -' 
fii    '~'    <-] 


o  ce 


g    ^ 


O  1-3 


^'^ 


X    -1^     M 


25   ^^ 

CD 


=2  o 


^   f^  H   fi 


cri  O 


M    CD    2 


o  P 


•S  -?fi;^i 


e 


;-^  ce  :; 
■^       ,—1 

S  "^  13 


'     '  i-H 
&£i— I 

rj 

ce  " 

XI  I— I 
0^    m 

^^ 


a 


>i  ce 

O)    OJ 

>  V. 


ce      ^ 


O^ 


0    o 


PLATE  10. 

Extraction  op  Upper  and  Lower  Roots  and  Lower 
Wisdom  Teeth. 


EH 


c 
<1 


o 
o 

p^ 

o 


Q 

o 


><1 


0) 

o 

o 


o 
o 


^   -2 


c3     -^     .— 1 


s  § 


bo 

s 

;^ 

o 

1=1 


o 

Ph 

p 


o 


■4^ 

o 

X 


o 


°  'S 


■4J 

rP 


Ph 

CD 

O 

O 


■75 

CD  i^H 

?H  © 

CS  (T) 

^3  i; 


o 

Ph 


o 

o 


o 
o 


4^ 
o 

o 


CO  c3 

•^  ^^ 

^  -^^ 

<^  rH 

^  .s 

o 

I — I  -u 

O  Ph 


Q 


03 

.p    ^ 


q-H 

o 

03 


03 


.2 

;h 
o 
P. 


-1-2 
o 

03 

•I — 5 
O 
;h 
Ph 


Ph       CD       03 
O     ^ 


03 


>>    ^       CD 


-1-3 

© 
U 

o 

fl 

«+H 

O) 

m 

Ph 

c3 

O 

rH 

o 

o 

-M 

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o 

•  r-H 

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n 

o 


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o 

^    S  g 

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i^    ^"^  =+H 

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Ph 
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Ph 


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02 

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The  Use  of  the  Elevator  for  Exteagting  Lower 
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Wall is 
Atlas  of  dental  ext 


Wig 

1919 
cop.i 

extract-jnnQ. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RK  531  W15  1919  C.I 

An  atlas  of  dental  extractions  with  note 


2002446553 


